 Good morning and welcome to the 25th meeting of the Health, Social Care and Sport Committee in 2023. I've received apologies from Stephanie Callahan and James Dornan MSP will be joining us as a substitute. The first item on our agenda is to decide whether to take items three to five in private. Are members agreed? Thank you. The second item on our agenda is a session with the Cabinet Secretary for NHS Recovery, Health and Social Care. The Cabinet Secretary will also be accompanied by the Minister for Public Health and Women's Health for this agenda item. Over the summer recess, using the European Priorities online platform, the committee invited members of the public to suggest questions that they would like us to ask the Cabinet Secretary. Today's session will be an opportunity for members to put some of those questions to the Cabinet Secretary and to ask questions about the programme for government 2023-24, which was published last week. For this morning's session, I welcome to the meeting Michael Matheson, Cabinet Secretary for NHS Recovery, Health and Social Care, Scottish Government, Jenny Minto, Minister for Public Health and Women's Health, Scottish Government, Caroline Lamb, chief executive of NHS Scotland and director general for health and social care, Scottish Government and Christine McLaughlin, director of public health also from the Scottish Government. We will move straight to questions. Cabinet Secretary, we are all very aware of the current situation regarding Covid-19 and the variants that we are seeing emerging. I am wondering if you could tell committee what data the Government is using to maintain vigilance about Covid-19 given their eyes in cases and those new variants of concern. Good morning, convener. Public Health Scotland will continue to monitor the levels of Covid-19 and testing for the new variant as well. That is largely carried out through those who admitted into hospitals where they may present with symptoms. That has been used to inform our approach to how we continue to manage Covid-19. You will be aware that the decision was made a number of months ago in line with other parts of the UK. Globally, to manage Covid-19 like any other sees no infection. That continues to be our approach. What we are doing, though, is monitoring very closely any changes to the pattern of infections and rates of infections. That will inform any further decisions we make on any changes that we may have to make to our approach going forward. We have also continued to keep in place a range of testing arrangements. For individuals, for example, being discharged from hospital into social care settings, we took a slightly different approach to some parts of the UK on this to maintain a level of vigilance in place, which means that we have a level of testing that is still taking place for vulnerable categories of patients, particularly if they are going to be transferred into social care settings. In terms of the newer variants that we are seeing, particularly the one that is causing concern just now, how is the Scottish Government monitoring that? We are engaged to the CMO and is engaged with the other CMOs across the UK. There is work being taken forward through the genomic sequencing process, which is obviously operating at an international level. There is work being carried out to test out, I do not know the full clinical details around this, which is to test out the impact of the existing vaccination programme against the new variant. That work has been carried out at the present moment. I also understand that the vaccination producers are all so monitoring to see whether they have to make any amendments to their existing vaccines, but that is all that has been taken forward across the UK and globally in order to monitor the on-going situation. At this stage, we are waiting for the reports to come back on that, but there is a level of vigilance that is seeking to try to make sure that any decisions that we make are on an informed evidence base. Given the continuing presence of the Covid-19 virus, what are the Government's plans to address transmission and the protection of people who are particularly vulnerable, for example in terms of ventilation requirements and clean air? Going back to the point that I was making earlier on, the clinical advice not just at a Scottish UK level but at a global level was that Covid-19 should be managed as a seasonal infection in a way in which we manage other seasonal infections such as flu, etc. The reason for that is because of the level of vaccinations that have now been provided at a population level, which gives us a much greater level of protection. Our intention is to continue to manage Covid-19 on that basis. If there is, at some point, a change in the clinical advice around that that we have to take for the action, we will respond to that. At the present moment, the clinical advice is that we should continue to manage it in a way in which we are at the present time, in a way in which we manage other seasonal infections. You have read in your priorities responses complaints around people with long Covid not being treated properly with regard to access to testing, best-in-class support and treatment in public awareness education. Is this in relation to people with long Covid not being having access to lack of consultation? You are complaining about people with long Covid not being treated properly with regards to access to testing, best-in-class support and treatment and public awareness education about long Covid. There is a range of work that has been taken forward by boards in the delivery of the long Covid treatment pathways, which has been delivered as part of the £10 million that has been made available for long Covid services. Around nine of our health boards have now got their long Covid pathways in place, and there are around five of them that are still developing those pathways. For example, in areas such as Greater Glasgow and Clyde, they have a long Covid service that allows GPs to refer directly into them for patients to be assessed and then for appropriate treatment options to be made available to them. What we have allowed boards to do is to design the services in a way that best reflect their local circumstances and what they believe is most appropriate for patients within their health board area. There are a range of services available. One of the challenges has been making sure that clinicians know that there are services available that they can refer patients into. Some of our boards have been undertaking work with colleagues across general practice to make sure that they are aware of how patients can be referred directly into those services. Some of them will also accept self-referos from patients into their service board patients to then be assessed and for an appropriate treatment programme to be put in place. That treatment programme is reflective of all that individual's circumstances. I do not know if Ms Minto wants to say a bit more, because she leads in some of this area of work. Thank you Cabinet Secretary, and thank you James Dornan for the question. During the summer, I spent some time with a group, a sportive group, providing peer support to people that are living with long Covid. I found that incredibly helpful, as did my officials, when we listened to the concerns that they raised there. I think that what the Cabinet Secretary has talked about in the fact that we have allowed health boards to ensure that they provide the service that is most important for the people who are living in their vicinity. That was passed on to the people, but it was very helpful from my perspective to hear what they were saying. Next week, I have two meetings, and the next couple of weeks, two meetings, one with Long Covid Scotland and also a round table with children and families who have been affected by long Covid. I think that that is a very important element to inform the work as we go forward. Thank you for that, Cabinet Secretary, and Minister. I never heard too much there about public awareness education. Could you maybe give us a wee bit more detail about what you intend to do or what you are doing to make the public aware about the long Covid? If I can answer that, I think that what I heard from those who are living with long Covid is that there does need to be more public awareness of the conditions that they are living in and living with. I had one very fit or had been very fit gentleman in his early 70s who used to go out walking a lot, and he now takes him over half an hour to walk half a mile. There is a need for better knowledge across the wider public about the impacts of long Covid, and I was pleased because I had officials with me at that visit, and I will in my meetings next week and the following week. They have heard this, and I am speaking to them about how we can improve awareness across the population about long Covid. Thank you very much. I have just got one more question for the cabinet secretary. What are your views on the suggestion that was made in your priorities that we lag well behind EU treatment regimes? For long Covid? Yes. We are on a pathway around long Covid in helping to understand it much more effectively, so you may be aware that there is quite a bit of global research now taking place around understanding the impact of long Covid and the most appropriate treatments for it. As it stands at the present moment, my understanding is that there is no single solution type or treatment type that is appropriate for patients. It is very often time to provide a holistic form of treatment. For example, the service that has been offered in Glasgow now, the long Covid pathway, has a range of different clinical inputs into it from physiotherapy through to occupational therapy through to other psychological services, all of which are about trying to address some of the issues that can present with patients who experience long Covid. I think that it would be fair to say that we are in a learning environment around how we treat long Covid. From some of the patients that I have met with long Covid, the presentation of long Covid is very often variable and their needs are very often very different as well, which is why some of our boards are looking to try and provide services in a much more holistic way with a range of different supports that can be provided to patients and to try to tell that to best reflect their circumstances. It would be fair to say that we are all learning more about long Covid and that will continue to influence how we look to deliver services going forward for patients with long Covid in the future. Thanks for that, cabinet secretary. Just back on the... We need to move on. Okay, right, okay. Emma Harper has got a short supplementary. Thanks, convener. Good morning to you all. Just a quick supplementary. I was reading about long Covid on NHS Inform and there are 16 different languages for people who might need support to access care. Is that something that the Government could consider making sure that people of multi-ethnicity and languages know that that's available, however, by using social media or whatever? Thank you, Ms Harper. I think that that's a very good suggestion and I'll take that away. Thanks. Thank you. Morning, cabinet secretary. I've heard some heartbreaking stories from long Covid kids, 11-year-olds with long Covid, unable to get out of bed, asking their parents if this is all that their life is going to be and saying it's just not worth continuing. What would you say to this child and family and what tangible help will be put in place? Have you put in place for kids with long Covid? We previously discussed this very issue about providing the services around long Covid and some of the pilots that have been taking place in England and how some of that could help to inform our learning here in Scotland, which I know that some health boards have looked at and learned from. For example, in areas such as NHS Greater Glasgow and Clyde, they have been using some of the long Covid funding to bring in paediatric occupational therapists, to what's specifically with children who are experiencing long Covid and also where necessary using paediatric physiotherapists as well to help to support children with long Covid. Health boards are trying to adapt their services to make sure that where there are young people who are experiencing long Covid, they have access to clinical teams that can provide them with the support that they require, and they are using some of the Covid funding in order to try to help to design that. The service that they now have in Greater Glasgow and Clyde, for example, has some paediatric services within it to help to address the need specifically of young people with Covid. However, if you have an individual case that you want me to have looked into and you want to share those details with me afterwards, I am more than happy to do that on behalf of the family. Long Covid does not just affect adults, it affects children as well, and services are being designed in a way to try to make sure that we meet the needs of young people as well. You are right, it does. Has the Scottish Government made any assessment of the economic impact of long Covid? It is a very difficult thing to do in terms of knowing the numbers of people who have long Covid. For example, some of the patients that I have met with who are experiencing long Covid, some of them have had a detrimental impact on their employment, so where they have had to, in some cases, to give up their employment, they are no longer able to continue with the job that they were in. Others have been able to adapt their working environment in order to accommodate the issues that they now have with long Covid, and others have been able to continue with their employment. There is a variable nature of it, but at this stage I couldn't give you a figure in terms of its economic impact and we haven't carried out an assessment to do so. Again, it will have an impact on individuals in different ways and also its dependent employers being prepared to make what they should do is make reasonable adaptations for employees that have a long-term condition to allow them to continue with their employment. It is important that employers do that when that is necessary. Very briefly, there are health boards that have not got a long Covid pathway in place. When would you expect that to happen? Will you be putting pressure on health board to come up with them quickly? The majority of them have pathways in place now. Those who do not are carrying out that work at the present time, and I would expect those pathways to be in place this year. The funding has been made available for them this year. It is part of the £10 million programme, so there is no reason for them not to do so, and we will continue to monitor them and the progress that they are making around that. Around the nature recovery, why haven't waiting times returned to pre-pandemic levels? A big part of that is because we are having to deal with the backlog that is built up during the course of the pandemic, so you will be aware that during the course of the pandemic a lot of our elective procedures, diagnostic procedures, had to be stopped, which have resulted in a significant backlog, but we are having to manage that backlog within existing capacity. New people have lade on to the list, and we are also dealing with the people who were previously on the list as well. That accumulation has made it extremely challenging. It will take some time to recover to the pre-pandemic levels. The other part that is added to this is that in some areas the levels of referrals have increased quite markedly. For example, in our cancer pathways we have saw a significant increase in the number of referrals into our cancer pathways, which are a way above what they were at a pre-pandemic level. In some areas there has been an increase of almost 45 per cent of an increase. We are not only having to deal with the backlog, but in some areas we are also dealing with a significant increase in the number of referrals into those diagnostic pathways, which is having an impact on wearing times overall. You will be aware that boards are making steady progress, particularly around long waits. We have saw a steady decline in both outpatient and inpatient long waits, and we are continuing to work with boards in order to continue to make progress with that, but it will take some time for us to be able to get back to pre-pandemic levels. The other thing that I would add to this is that we are also working through the centre for sustainable delivery. It is in a programme of work to try to make sure that we are maximising capacity within our services at the present time. For example, we are carrying out work on looking at, for example, the use of theatre times to look to see how we can make sure that we are maximising that. We are using a new digital tool to help to maximise that, which could give us up to potentially an additional 30 per cent capacity. We are trying to, through the centre for sustainable delivery, try to get consistency across boards and how they maximise capacity within their existing services. Some of them are not operating at the capacity that they had pre-pandemic, and we need to make sure that we get greater efficiency in there as well to try to maximise use of those resources. That combination, the history of it, the increased referral rates and trying to make sure that we maximise the capacity that we have within the existing system to use it to its full potential. Around national treatment centres, what impact are we having on waiting times for offer period and cataract operations, and what impact are we having on unschedule care and patient flow in secondary care? The national treatment centres, for example, there is one in your own health board area around Fife, which is helping to deliver what will be on-going improvements in the delivery of orthopedic and ophthalmology services, which will help to reduce the weights that people have got. I do not know the exact data for Fife, but I know in Highland that they are ahead of schedule in terms of their programme there, and also that it is helping to reduce weights for patients within their own health board area. That will also help to support NHS Grampain because patients from NHS Grampain will go to Highland NTC as well. Also, once we bring on phase two of the NTC, the Golden Jubilee and the fourth NTC at Fourth Valley, that will give us additional capacity again on that. In those individual board areas, it will help to reduce waiting times, but it is within the wider context of that increase in demand that we are facing. In terms of how the impact that has on unscheduled care, one of the challenges that you always have is that acute priorities can very often displace elective at work. The benefit of having NTCs is that it is a protected environment, so it is there for elective purposes. It gives greater certainty around the level of elective work that can be taken forward in a way that can be buffeted within the general setting of acute priorities unscheduled work having to take priority over elective procedures, purely for clinical reasons. It gives us that level of protection in the system that will assist boards with their planning much more effectively over the course of not just within months but over the course of a year because it is a protected environment. Are national treatment centres being considered for any other specific areas like cancer treatment, which would be part of transforming cancer care? Our plan is overall to have 10 NTCs across the country. We are moving towards phase 2 of that. That is being considered within our capital programme, which is being reviewed at the present time because of the cuts to our capital budget. It is primarily focused on elective-type procedures rather than acute care in itself. I do not know off the top of my head if there was anything considered—Caroline can say if there was anything considered around cancer. It is for NTCs, but it was predominantly around orthopedics ophthalmology, endoscopies and so on. The national treatment centre programme was very much designed to deliver against elective care. As the cabinet secretary said, the importance of that is being able to separate that out from unscheduled care so that elective care does not get impacted when there is real pressure on unscheduled care. We have introduced a number of early assessment centres for cancer that bring together rapid assessment and treatment centres, so that has been the focus that we have been taking around cancer. Good morning. Social care staff are set to benefit from a pay uplift to £12 per hour. That will mean an increase of more than £2,000 a year for some staff. What difference do you anticipate that that is going to make? Our social care staff are critical to supporting and sustaining our health and social care system. They are interlinked and key to one another. Traditionally, the social care setting has been undervalued and that is reflected in the rate of pay within social care compared to healthcare. We have taken forward a programme of work that has tried to help to make social care a more attractive environment for people to work and to reflect the value that we have for our social care staff, which has resulted in an increase in their pay. With an increase of £12 an hour over the course of the past two years, that is a coven of what we have already put in to take it up to £10.90. That is a coven of more than 14 per cent of an increase in two years for the sector. The objective behind that is to make it better for attracting people into it as a profession and to help to support retention of staff within social care in order to give it more resilience. The principal objective is to try to get more people into it and also to help to support and encourage those who are in it to remain within it as well in the future by providing them with greater pay. The Scottish Government has avoided NHS strikes through negotiation of pay deals for NHS staff, trainee doctors and trainee dentists. I think that Scotland is the only UK country that has avoided strikes thus far, which I think is good news. How will this help the Scottish NHS and how will this help the Scottish people? Any form of industrial action within our NHS is hugely disruptive. It is not just disruptive to the staff or the process of managing the NHS, it is hugely disruptive to patients. We only have to look at the experience in England in particular where there has been repeated industrial action, where I believe that there is something like over seven and a half million patients now on wearing lists, but also they are close to almost a million procedures and appointments being cancelled as a result. Now that is the immediate impact. That will have an accumulative impact going forward because it backlogs things into the system. So that is the immediate impact it has. The other aspect around industrial action and also persistent industrial action is that it demoralises staff. Staff end up feeling undervalued and it is a system that is already under enormous pressure. Staff are under enormous pressure and adding industrial action into my view would just demoralise staff even further and make them feel undervalued and all of the consequent challenges that go with that. For example, my deal with the junior doctors is that I acknowledge and recognise the real challenges that there were around junior doctors over pay erosion and we managed to negotiate an agreement to avoid industrial action with them on that. My big concern is that industrial action not only is disruptive to patients but it also serves to demoralise people who work within the system even further and all of the consequent challenges that then go with that going forward and people being put off working within NHS as a result of the disruption and the difficulties that go alongside that. There is a monetary cost to settling these matters but I actually believe that we would create even bigger challenges for ourselves if we did not try to address these issues and the chance that would come from having industrial action would be even greater and worse than it would be in trying to deal with some of the financial chances that go with the pen negotiations that we have had. My first question is that the chair of the BMA has said that Scotland needs 2,000 gps and yet you are struggling to actually find 800. My question is how are you going to deliver the primary care services that patients deserve in Scotland? If I can just correct you first of all, we are not struggling to find 800. We are actually a head of trajectory on 800 so we are also recruiting into GP speciality. I think this year we are actually we are not only 100% I think we were actually over applied to for GP speciality training as well. So we are in a strong position in delivering on the 800 commitment that we made in the course of this parliamentary term and also in increasing the number of GPs in training where all speciality options have been taken up this year as well. In order to add into that we have also been expanding medical training so we have given a commitment to increase the number of medical students within Scottish medical schools by 500 so this year that's expanded by over now expanded by 300 and we're on target to increase it by another 200. Believe it or not the BMA has asked us to slow down a bit in this issue to make sure there's capacity for training within the system as well for medical students. So look there are challenges within our medical workforce. I wouldn't want to give people the impression that we are armed but I think it would be wrong to give them the impression that we are struggling because we have been able to recruit into the the offers that would be made available for general practice and also into the training programmes as well but we need to continue to do more because general practice is under huge pressure and a big part of that is not just the GP workforce but it's also the multidisciplinary team we have in primary care because a key part of what we'll have to do in primary care in the future is to make sure that we have a broad range of healthcare professionals that can meet the patient's needs in order to meet the increasing demands that primary care is going to face in the future so that combination is going to be key to making sure we continue to try to meet those demands as best we can. My follow-up question cabinet secretary on GPs then it seems to be a major issue in rural healthcare which is in crisis so things are so bad and we we brought it up at committee last week that the community of Breymar is trying to head hunt its own GP because the local practice has struggled to recruit a suitable candidates and residents have actually had to take action into their own hands and do their own recruitment and in Aberdeenshire alone five practices are now managed by the Aberdeen health and social care partnership it's about to be six GP practices so the wheels are definitely off the bus in the northeast northeast of rural healthcare with regarding GP practices so two two questions why hasn't the SNP done more to address this crisis in primary care and with with GPs and make rural Scotland more attractive for health professionals and the second question cabinet secretary is does the Scottish Government intend to look at the 2018 contract in the context of rural practices thank you okay so let me try to deal with them those issues in terms of rural general practice there are challenges in rural general practice there have been for many years chances in rural general practice particularly in single handed practices in some of the rural areas where when the GP chooses to leave or to or to retire it can be difficult to recruit into these practices that can be for a variety of different reasons but I agree and accept there is a challenge there in some parts of rural Scotland so what are we doing to try to address some of these things so we've got the scottgem programme which is about trying to help to recruit and encourage doctors to work in rural environments we also have the i'm going to get this wrong i called it the golden hello but it's not the golden hello it's the busery programme which again is to support GPs individuals who may be GPs working in rural areas as well to give them financial support or financial incentive as part of the programme and the third thing we're doing is that you'll be aware we're setting up the the centre for rural remote healthcare which has got a programme specifically designed to look at how we can create and deliver greater resilience within within both in particular in primary care going forward as well in order to try to deal with some of these systemic challenges we have in recruiting people into our rural areas so that combination of programmes to try to help to retain and support people within rural settings creating financial incentives through financial support for working within rural areas again are all programmes that are aimed at trying to support getting people into general practice within our remote rural areas your point around the number of practices that are now within the NHS this has happened historically so over the years some people give up their contract and they're taken over by the NHS it happens in urban areas as well as in rural areas but what i do know and having just had a meeting with the health and social care partnership in Grampian yesterday along with the chairs of the with the IGBs is that they have a programme of work which they're taking forward in order to look at creating a much more sustainable approach to deliver primary delivery of primary care within the NHS Grampian area and that's a piece of work that they're already taking forward and expecting that completed by the end of this year to make sure that they deal with some of the we've got a plan to deal with some of the very specific issues that they're experiencing within the NHS Grampian area in itself so i've explained to them that i want them to look at how they can work in an innovative way using the existing system to help to try to deal with some of the particular challenges they have within within their area cabinet secretary do you think it's acceptable that a local community has to take recruitment into their own hands to find a GP well look the delivery of primary care within the local area and the contract is direct with the health board i would expect a local community to engage with the health board and the health board to engage with them around how they're trying to address the issue of concern which they have to make sure there is adequate general practice services within their area so i would expect the health board to be proactive in doing that and if they're not i'd be more than happy to make sure that they do engage with the community in Bremar if there's a need for them to to do so so but it is important that there is a level of local understanding on what's the most appropriate way to try to deliver services locally within the primary care setting secretary because there's a big difference between 800 and 2000 and if the BMA is saying that you need to recruit 2000 in scotland do you dispute that figure i don't know where the 2000 figure comes from from the BMA and what analysis i i i i i i i i do understand that you know that the the groups of the BMA will will lobby and push for what they think is the the best approach and i'll always engage with them in a meaningful way and i think this afternoon that I I Am Actually Meeting With The BMA to compared to the business to Primary Care itself anyway. We'll continue to look at what more we can do to try to help to support primary care. Because it's a critical part of our healthcare system and we'll actually find even greater demand in the years ahead, just given the demographics we have the country and the disease burden which we face as well. I'll always look to see where there's more we can do and I'll always engage with the BMA on the issues that they raised a chynnwch i yw rhoi'r rannu'r bwysig i'r oedd ymddangosol i'n bwysig i'r holl i'r newid. Ond, gweld i'r gwaith yw'r glas yn fawr. Felly, mae'n gofynol i ddweud, nad yw'n ddweud ond mae'n gweithio i ddweud, ac mae'n gweithio i ddweud, mae'n gweithio i ddweud, mwy fawr o'r glas yn fawr. Mae'n ddweud ei wneud o'r fawr, ac mae'n ddweud i ddweud, ac mae'n ddweud i ddweud i gweithio i ddweud. o blwyddyn o amgylcheddodol rhannu Ballachol mewn c manner a rhai cwyrtu iddyn nhw yngydig o ddim yn cymryd ddiwedd ar y ffordd o'r rai cyfwyrd trwy'r awd. Felly mae'n gwasanaeth mae'n ffordd o ffordd i gyd, ac mae'n gweineb o fewn y ffordd o fewn pholeneddau cyfrwysig yn y ffordd o'r hyffordd. Mae diogelwch, a'n ceisio i gweithio unrhyw deithas unrhyw ddawg, ond bydd y nifer wneud, doingodd, mae'n meddwl i'r gymryd yn ddiolch i'r byd, mae'n meddwl i'r pethau i'r byd, mae'n meddwl i'r pethau i'r byd fel cyddiad.�י'r meddwl i'r cyfan i'r glennatau drwy y gwaith ydym yn gweld o'r cyddiad ardann iawn mlynedd yn meddwl ei sgif公wysol, fuddio'n meddwl i'r cyfyrdd i'n meddwl i'r gwahodd gyllideb yn gwneud Shouldn't people try to swerthw shares so that we are both training from an educational point of view into specialities is sufficient to meet what we think will be the intending needs going on A local level of health boards that hofer replaced the brightest arrangements that are necessary should there be changes to the numbers of GPs that they have in their area 그걸 required of monitoring that and to try to make sure that they're putting in place the right arrangements that might be necessary should there be changes to the numbers of GPs that they have in their area or whether there is a significant increase in their i'n gweithio i gael ein system wedi'i ddechrau'r cynllunol yn y gweithio i gyflwyno'r gwaith, ac mae'n gallu'n gweithio i'n gweithio i'r gwaith. Carol Locking. Yr unrhyw ysgolgau ar gyfer y ddych chi'n cymryd yng nghylch yn gweithio, wrth i ddim yn gwneud hynny, mae'n ffordd yr oedd ymddangos i gael ei ddwy, oedd yn cyflwyno'r ffordd yn y ddych chi'n gwneud? Nid oeddiw ymwneud gan ymdod ar gwaith i dryfnodd yr unwyddiadau yn ystyried o'i ffordd o'i gweithio, o'r gwaith pethau ymdodd pan yn eu gyda'r ddau y gallu dwylo ond genna ifreiddiadau yn i-froedd o lawr. Ac anoddiw i'w gwneud i'r wneud addysgu pethau i gael gwneud o'r sgwlad i gyfnod hwnnw i gael unwyddiad a'r ganwyddiad a'r unwyddiad we have had so far is very much around trying to get those balances right. I don't know if Caroline wants to say anything more on that but it's still our intention we're trying to make sure that we take the employee side with us to get this balance right. I think as part of that this isn't about we wait until april and then we suddenly implement so all our NHS boards are currently testing out different aspects of the legislation and the operationalisation of that so how that actually gets put into practice so that will provide us with some important learning and as the cabinet secretary says that's very much being done in partnership with our trade unions as well. That's excellent my second question was around the engagement with the trade unions so I'm really pleased to hear that because obviously I've been lasing with him myself so my final question was around the link that it may have with the up-and-coming patient safety commissioners bill so we managed to get some amendments at stage 2 and think that that should work together so I'm interested to know what discussions or what thoughts you've had around that. I'm not familiar with the amendments that you're referring to but I'd be more than happy to take that away and have a look at what those amendments were to to consider how they would work in with the with the staffing levels on that. I don't know where do you want to say something that yet? We've got stage 3 of the patient safety commissioner bill coming up in the next couple of weeks so I think that's an opportunity there for us to take good licence of what you've just said and look at how we incorporate that into the debate which I'm sure you will be covering that in your speech. That's very helpful to know that you are still sort of committed to that it was just the link between safe staffing and state safe patient outcomes is what we want to make sure is taken forward that's great thank you. Emma Harper has a short supplementary. Thanks convener it's just a quick sub on the Scottgem it's been really successful in Dumfries and Galloway my understanding is the retention has been fab I'm interested to know cabinet secretary whether Scottgem is unique to Scotland and I know we've got GP issues across the four nations so is that something that you're aware of other of the four nations considering a Scottgem equivalent programme because Scotland is leading the way with this? Yeah is it and I'm aware in Dumfries and Galloway they've had benefit from the Scottgem programme it was one of the issues that I raised at the last four nations health minister's meeting where we were discussing issues around recruiting and retention particularly in some of our more rural areas and I actually highlighted to them the Scottgem programme and I've offered to share their information around how the programme operates and the benefits we've had from the programme so far with other health ministers in the UK which are making available to them so and there was an interest in looking at how the Scottgem programme has worked. Okay thanks I'm going back to Emma Harper for our next theme. Okay thanks so I'm interested in one of our themes is about obesity and how do we tackle obesity and I'm really interested in issues because of just recent questions that I've submitted in chamber regarding ultra processed foods as well as we call them high fat sugar salt foods as well but there's some great research by Carlos Montiero who's a professor of nutrition and public health in Brazil and other books that have been quite popular recently by Chris Van Tullican and Henry Dimbleby that talk about ultra high processed foods and how do we I suppose understand more about the relationship between the foods and not just sugar fat content as well so I'm interested minister probably as it's a public health portfolio is around the you know the powers that are available for us in Scotland to bring forward regulation about marketing and and sales of some of these types of foods. Are you able to give us an update on work that's been taken forward? Thanks Emma Harper for that question and it's something that I've been having a lot of discussions over the summer with my officials. We will be doing a consultation in the autumn with regards to foods that are high in fat sugar and salt or salt and we're looking at different foods to perhaps concentrate on so for example crisps confectionary cakes that kind of area but we're consulting on this and then we're also looking probably going to be consulting on promotions as well whether that's meal deals unlimited refills location of products in stores so we've got all all these that we're going to be looking at I mean I was commenting that over the summer I was shopping and I got a voucher at the end of my shop for a cake and I was thinking well why couldn't I have got an option of a voucher for a banana so it's thinking about things like that. You commented on the fact that instead of a bill we're bringing regulations and we believe that this will allow us to move swiftly with regard to that and efficiently circumstances change which has allowed us to to bring in the regulations as opposed to a bill but the time scales we're working a pace on them. Now with regard to ultra processed foods I know the two publications that you were talking about and there's also been a number of articles and newspapers and also a number of podcasts about ultra processed foods. I was in a meeting just last week with Food Standard Scotland and Public Health Scotland where I raised this as something that I would like to get a bit more information on currently with regards to ultra processed foods we look at evidence from SACN and currently there is no specific evidence but and that's what the Scottish Government bases decisions and policies on evidence but we certainly need to do further engagement and consultation on ultra processed foods and that's something I've asked my officials to look at. In our briefing papers it talks about the cost of obesity and I know that the language is changing around that so rather than label somebody as a disease we should be less stigmatising in the language and say it's a person living with overweight or obesity. Is that something that we should be thinking about making sure that people understand that instead of blaming people for what may not be their own fault because of the issues around poverty and the fact that certain access to fresh fruit and veg apparently some neighbourhoods don't have fresh fruit and veg in their local shops so I'm interested in what work is being done to de-stigmatise the language around obesity as well so that we can support people in choices of food but also access for food as well. I think that's a really really important question and actually was highlighted to me very starkly yesterday when I heard from a mother whose son was described as fat and obese and that has given him a dreadful lack of confidence and I think you're absolutely right. I think the whole part of language is incredibly important and also how we work with local authorities and schools and other public bodies to ensure that that is spread out across the way that we operate in our public services. I think one example bringing it in is the Good Food Nation and it talks about ensuring that people and children are getting the opportunity for good and healthy food and I saw that in operation last week at a primary school in Edinburgh where they were talking about breakfasts and healthy foods so having your wotobicks and fresh fruit so I think there is a whole thing about language and I think that starts in an education centre as well as across the general public so something very cognisant of. I'm just a final question and the Scottish Government introducing the free school meals for primary school children and expanding that. Is that something that will help tackle this what's now being called commercial genic malnutrition environment because of the way that the big manufacturers are targeting young folk with maybe unhealthy choices but the free school meals that have been introduced or have been widened by the Scottish Government that's something that should help address some of our issues that we're seeing with overweight young people as well? Absolutely. They say a healthy start in the day is so important when it comes to breakfasts but also with regards to free school meals as well it is supporting families that may not be able to afford the foods that we would like them to eat and it's really part of a whole policy within the Scottish Government of transforming the food environment and also as you will know recognising that we need to bring people out of poverty to improve the general health of the population. Minister I think we all agree that with the right policies we could have childhood obesity in Scotland by 2030 so I really would like to understand why we've gone into another consultation process you know and why we can with the evidence that we have look at regulation or in fact I would be interested to know whether there was pressures put on yourself or government to not go for primary legislation in this case because we know that we could change the outcomes for such a large number of the population in the future. So there was no pressure put on us from other organisations not to bring in a bill and then an act. It was through a change in circumstances and evidence from England that allowed us to bring in regulations or via regulations however when we're bringing in anything to do with food there has to be proper and robust consultation and that's what we're doing just now to ensure that we are bringing in the right policies evidenced policies which will improve the the ability for people to to buy the right food. I think can I ask you know as time sensitive this has gone on for a number of years can you make a commitment that you will make sure this is at the top priority for the government in terms of any business that goes through? This is certainly a priority and it sits in my portfolio and it is a portfolio priority clearly sitting under public health and I think from my own perspective understanding from the education side and seeing the joy on some children's faces that perhaps hadn't tried different fruits is really clear and I think that's why it's important to to work with education and also work in to ensure that families understand the importance of food and to be quite honest making food a pleasure and not just something that you you have when you're watching the television or whatever but I think that that's where I'm coming from and I think as I said it's a huge area of just changing the food environment and also the health environment across Scotland. Just got one tiny other question that I'm interested in is it's around the daily mile I just wondered how much commitment you think there is across Scotland in the daily mile if it continues to be a priority for you? Yeah I was up in Elgin in the summer and Elgin was the first place I actually came across the daily mile and when I was in the health centre there they were talking about the importance of exercise which is of equal standing to what we actually eat and the health centre was explaining how they are supporting families not only in the daily mile but also from babes up I think it was basically eight months to eight over eighty the people were attending the health centre to be able to get support with their fitness whether it's simply doing the daily mile or actually some more physical swimming or weight training so yes that that's really important too. Evelyn Tweet has a very brief supplementary on this. Thanks convener obviously during the cost of living crisis some people are having to eat highly processed food that probably isn't that good for them out of necessity. Now we've seen preventative diseases like rickets the numbers have increased have the Scottish Government thought about how we're going to deal with that sort of issue? So I think it's fair to say and I've learned this in the portfolio that you can never be fully confident that you have eradicated a condition or a disease and I have very regular meetings with my officials that cover different diseases and conditions. We haven't specifically talked about rickets so I will make sure at my next meeting that that's something that we do. We're going to move on to our next theme and I'll pass to Gillian Mackay. Thanks convener and good morning to the panel it's reported in the press this morning that the UK Government are likely to announce a ban on disposable vapes in the coming weeks. I welcome the Scottish Government's commitment to consultation on banning these however while that work is under way harm is still occurring many of these products are being displayed in windows and alongside suites are on the end of aisles in full view of children and young people. I wrote to retailers asking them to proactively put these behind cover but many declined citing that they will comply with any legislation that comes forward. Given this is the Scottish Government planning to use their current regulation making powers to move quickly to put these products out of sight particularly out of sight of children and what other additional measures such as plane packaging and restricting advertising are being considered. I'll take this. Thank you Gillian Mackay for the question. It is a hugely worrying situation that we're seeing and we've got a number of strands of work within this area. Just last week I met at a round table event co-hosted with Lorna Slater talking about from an environmental perspective the impact of single use of apes. I also have a meeting on Saturday with young children is at that meeting. There was a real strength of feeling that we need to consult more with younger people about what the best thing to do is. What we're currently doing is building on regulations that are already in place and trying to make the promotion and sale of vapes to under 18s, making that and really reviewing that to ensure that we've got the right processes in place. We consulted I think in 2022 on the restrictions on advertising and promotions and we're looking at that as well just now but there is very much on-going work and I'm working closely with my officials to ensure that we have the proportionate and right response to the current situation with regards to vapes. From that answer is there work underway particularly about putting them behind cover similarly to the way we do with with cigarettes currently and that's one of the the biggest concerns that we're hearing from from parents is the pervasiveness of these of these products particularly in shops that can be reached by toddlers on on ends of aisles in in some shops and if that was cigarettes we'd rightly be outraged that it's the same addictive ingredient that is in these products too so is there consideration being given to put them behind cover? As you'll know we've got the tobacco action plan which will be coming out in the autumn this year and it absolutely is looking at vapes and where they are in shops. I too like you have had the stories the experiences of mothers in supermarkets with vapes at the eye level for children in the bright colours which attracts them so get very very aware of that situation and it will be covered in the tobacco action plan. I hosted a round table yesterday that was attended by Emma Harper and other colleagues as well and we heard from paediatricians and parents who are concerned about the addiction children are currently suffering and the potential long-term health impacts. We've never needed large-scale nicotine cessation for children before but that is potentially looming and many of the nicotine replacement therapies that we currently have are only licensed for children aged 12 and over and we've anecdotally heard children as young as eight using vapes who may need support. What work is currently underway to develop pathways and support advice for young people and parents who are facing this addiction? So thank you for that question and I'd be really interested to get the read out of the meeting that you chaired yesterday. There's quite a bit in that. I think one of the things that ideally would be through prescriptions but currently there are no products with regards to this that are approved by the MHRA but that is something that we are looking into and I'm working with my officials in pharmacy and such like with regards to that. Thanks Camilla. Sandish Gohani. Thank you. So I've got a question around alcohol. The turning point 218 service in Glasgow which helps support female offenders to rebuild their lives after drug alcohol use is facing £850,000 in cuts. The 218 service is primarily funded by the Scottish Government. Can you explain the rationale for cutting this service and can you commit to restoring funding for this vital service? I know the 218 service from my time in justice. It's not something that's funded by health. It's first, if I recall correctly, it's funded through the community justice programme directly. I know that the justice secretary has been engaged and if I recall correctly, I think that Parliament was raised and she said that she'd engaged with the matter but it was in relation to community justice funding which was having an impact. Christine can say a bit more about that. I can't fully answer your question and we can follow up with detail but there have been previously discussions about turning point as an organisation but the cabinet secretary said that the majority of the funding is through justice. There's a small proportion in relation to alcohol and drugs services as you say. Something that we can take away and provide a response on that for you is part of the understanding of what its budget is compared to where it's been and for what services. Just to follow up on what Gillian was asking about vaping. My real concern, a huge concern, is the number of kids that are vaping and openly vaping. It's not sort of behind the bike sheds having a cigarette but it is walking down the street, it is in schools, then the toilets and it's like a vaping toilet and then they hide the vapes and the lights which is hugely worrying. So I know you said that work is underway but when are we going to hear about things that we can put into place concretely to stop under 18s from buying vapes and look it is illegal already but trading standards just can't cope so which really needs something to be done here. I think that's a fair point and when I was visiting one of the schools in my constituency, one of the teachers came out and in our hand were eight brightly coloured vapes and so I absolutely agree that it is a very difficult situation that we're in. As you've rightly pointed out, it is illegal already to sell under vapes to under 18s and that's something we've been discussing with our local authorities to ensure that they are recognising that where possible. As I mentioned to Ms Mackay, we have the tobacco action plan coming out this year. I'm now going to move to Paul Sweeney. Thank you very much, convener, and thank you to all for attending today. There has been a lot of correspondence, certainly from members of the public, and our call for feedback on the state of the national health and social care system on mental health in Scotland, in particular the waiting times for CAMHS services. The last quarter's waiting times data shows that 73.8 per cent of children and young people were seen by CAMHS within 18 weeks. That is lower than the previous quarter and falls short of the Scottish Government target for 90 per cent of people to be seen within 18 weeks. I understand the delivery plan for the mental health strategy. We'll look at when boards can reach the waiting standard but will that plan be accompanied with funding so that health boards can build the required capacity to meet that target effectively? Our CAMHS services have expanded enormously over a number of years, but demand for them has increased significantly as well. I recognise the concerns that Paul Sweeney is raising around the unnecessary weights that children and families are wearing to access some of those services. The intention behind the delivery plan that we are going to take forward is to try to help to make sure that there's a much more consistent approach to how services have been delivered across the country. You'll be aware that some boards are performing better than others around service delivery, but there's a need to try to achieve greater consistency. I can't give a commitment on the funding aspect at this stage because obviously we're going to get into the budget round for next year. We need to see what the budget settlement is as well, but the need to make sure that we continue to expand and develop our CAMHS services is a priority for us. I know that Marie Todd, the Minister for Mental Health, spends a lot of time trying to make sure that we are taking forward the right approach to get a greater consistency of service delivery across the country. The variation is one of the biggest challenges that we face around CAMHS services. The objective behind taking forward the delivery plan is to try to help to make sure that we get a greater consistency of approach. Can you tell us a bit more about the mechanisms that you're looking to deploy to ensure greater consistency and to reduce variation? What operational changes do you propose to make specifically? I recognise that there is an ability for you to commit to specific funding at this stage, given that it's not necessarily in your gift, as Cabinet Secretary alone, but there is a broader objective to allocate at least 10 per cent of expenditure to mental health as set out in both your party's manifesto and in the group. The Butehouse agreement, is that still the target by the end of this Parliament? Will there be a commitment to it, that 10 per cent target, or will there still be a proposed cut in real terms to the mental health budget? Relation to your latter point is still your objective to get to that 10 per cent within this parliamentary session and to take that forward over the course of the next three years. In relation to the specifics you're asked, I don't have those to hand, but I'd be more than happy to come back to the committee to give you some more detail around some of the specific measures that we are looking to take to try to address some of the issues around consistency of service provision. Before I ask this question, I'll declare an interest in that I'm a registered mental health nurse with current NMC registration. I was also the Minister at the time that commissioned this review. Can I ask the Cabinet Secretary for what recommendations from the mental health law review that the Scottish Government will be taking forward and is able to give a time frame on that and what work is currently under way in terms of reviewing mental health legislation? There was a range of recommendations made by John Scott in his report. I think that we accepted all of the key recommendations that were set out within his report. Some of them will require primary legislation changes and we are aiming to take forward primary legislation, hopefully within this parliamentary session, in order to give effect to some of the primary legislation that will be needed to implement the recommendations from it. I also want to pick up on the recruitment crisis in social care, another major issue that has been fed back very strongly to the committee. The programme for government included a commitment to a pay rise of £12 per hour for social care staff, and if the Government had acted when those calls for the £12 per hour pay rise were made three years ago, that increase would now be worth almost £14 per hour after inflation. Does the cabinet secretary think that that is sufficient to address the scale of the recruitment and retention issues in social care bearing in mind the opportunity cost of not acting? It is one aspect. Part of the challenge that we have had around social care is because the reality is that we as a society have not valued it as much as we have other professional groups, particularly comparing it to health. That is a wider societal issue that we have to be honest and open about. The consequences of that are now very clear, given the challenges that we face in social care. Pay is one part of it. The other aspect that is really important in social care is to see it as a career of choice for people. There is a career pathway, there is a progression in social care, and there are opportunities that come from that. One of the areas that we are looking at is to see whether there is more we can do to try to help to create career pathways in social care that encourage people to go into it, to build up experience within it and to have the opportunity to go into other professional groupings. For example, one of the areas of what we are looking at is that there is a way in which, through things like the nursing apprenticeship model for example, we can create pathways into regulated professions that, having extensive experience in social care, allows you to progress into some of the regulated professions through a different route from what is available at the present moment. I think that trying to create those career pathways are critical to encouraging people to go into social care. Pay is one part of it, but it has to be a credible career option for people. There is a lot more that we need to do around that. Some of the work that we are doing is to try to give some very specific routes that would encourage people to go into social care with a route into other professional groupings if they choose to do so at some point in the future. Thank you, cabinet secretary, for that response. It was fed back very strongly by the Royal College of Nursing and the nurses in training felt really that they were not able to continue with their studies because of the financial costs to themselves in that potential apprenticeship led model with an employee status at the outset would certainly be a way of remedying that. But one of the other major issues that has been fed back certainly was the abolition of non-residential care charges that certainly came back very strongly from stakeholders. Non-residential care charges are not only still in place, but in Glasgow they are almost doubling in cost. There was not any mention of care charges in the programme for government despite the strain of the cost of living crisis and the impact that is having on some very vulnerable people is ending non-residential care charges still a priority for the Scottish Government or is it not something that is on the radar at the moment? It is still a priority for us, but it is a challenging area of policy for us to take forward in the existing financial climate. Options in being able to make more progress in this are largely limited because of financial consequences with it and not being in a budgetary position where we could actually advance it. It is still a priority. Should finances become available to us to do so, we will progress it, but at the present moment we do not have financial provision to be able to take it forward. I was one of those social care workers who worked in a care home and then progressed to do nurse training and became a nurse for 30 years. The opportunities for career progression is something that we should absolutely pursue. The national care service aimed as we were progressing with the plan was to have a national standard approach to providing education for caregivers. Is that something that we would see as we progress with the national care service so that, no matter where you are in the country, you have provided the same level of education that would allow you to be more mobile in a career pathway? Yes, it is. It is one of the potential benefits that you get from a national care service as it allows you to create a more consistent pathway, both training and career options for individuals in the social care setting and the opportunity to move around the system in a way that they might not be able to do at the present time. Part of the challenge in social care is that it is a very fragmented sector. You have public sector provision, voluntary sector provision and independent sector provision. They can very often all, despite the fact that there are national standards in terms of care delivery, have variations in how they operate. One of the benefits that we get from a national care service is to try and get a more consistent approach across those three areas, which can help staff around training and potential career routes. The fractured nature of the way in which the social care system operates at the present time is one of the core purposes behind the national care service. I think that that can help to deliver much greater consistency across the country. Just a question on the independent living fund. In the programme for government, there was an announcement about reopening of the independent living fund. Are you able to speak a wee bit about that? I am particularly pleased to see this reopening because when I was a minister for public health, I set up the independent living fund. When it was being closed down at a UK level, I chose to establish an ILF here in Scotland specifically. Our ability to reopen it, which will have an initial budget provision next, financial year of £9 million, will enable us to open it up to around 1,000 additional disabled people who very often have much more complex needs. One of the real strengths of the independent living fund is that it gives individuals much more control, particularly those of complex care, much more control over how their care arrangements are delivered and by who as well. I am particularly pleased that we are able to reopen it for new people to apply to it. We are now taking forward the work that will be necessary with the independent living fund to put arrangements in place around opening it up for individuals next financial year. You mentioned the voluntary sector as part of the complexity in provision of care. We speak often at this committee about the third sector and as it relates to social prescribing, for instance. Are you able to tell us about how the Government plans to ensure the viability of the third sector agencies in support because they are quite important to social care in the whole provision of care services for people? Some of the additional finance we are making, for example, for increasing periods will obviously benefit those organisations from within the voluntary sector. I think that if we can help to retain and recruit into social care, all parts of it will benefit from that independent voluntary and the public sector. We need to make it an attractive career environment for individuals and the rate of pay needs to reflect that as well. Would I like to go further on pay in social care? Absolutely. However, we have to operate in the financial environment that we have. The reality is that £12 an hour is a significant uplift, but to go beyond that would create a significant challenge financially across the portfolio. It has to be an attractive environment for people and pays one aspect of it. The other bit that I mentioned to Paul Sweeney around creating good career pathways are critical as well. Like your own career pathway, they are critical to not just supporting social care but also how it relates into healthcare going forward. Do you have time for a quick question about palliative care? No, we've got several other members who want to ask questions. I'm going to move to Paul Sweeney. I want to quickly pick up on the work done by the Covid-19 recovery inquiry into dentistry in Scotland. As an area of concern from a number of stakeholders, the British Dental Association have said that there remains uncertainty over whether the Scottish Government reform proposals will be enough to halt the exodus of dentists from NHS services, certainly from personal experience for the first time ever. My check-up was cancelled because the permanent dentist left the practice line on locums to cover it. What is the Scottish Government doing to take forward the recommendations made by the Covid-19 recovery committee's NHS dental services inquiry, particularly around consideration and costing of different service model options? I think that we were very clear as well that payment reform was the first step on the journey to looking at dentistry. We will be working with the BDA on and more widely other dentists as well on governance and workforce. I have asked for and we are arranging a meeting with the other four nations with regard to dentistry because this is not just a Scotland only issue. There are issues across the whole of the UK with regard to dentistry. Part of that is, as a result of a loss of new dentists coming in for two reasons. One, the pandemic, we lost a whole year, which was about 160 student dentists, but then also Brexit, and how we can actually encourage dentists from across the world really to come into the UK and Scotland. There is a lot of work happening with regards to that. This year I am pleased to say that there are 183 or 184 students studying dentistry, so that will help to move on. There has also been a lot of work with regard to working with the directors of dentistry in each of the health boards to find ways within their specific areas to support dentistry coming in, specifically in the rural health boards, where, similar to what we were talking about earlier, attracting GPs. There is work to attract dentists as well. All that is incredibly positive work and work that myself and my officials are engaging with dentists to take forward. A constituent of mine, Stuart McGraw, is a dentist who lost his associate during Covid. He stepped up to more than double his work to serve his community and his patients, but the funding did not recognise this individual case because it is individual. It is meant that he has had to move in with his parents to try to keep his practice afloat. Is this something that you would be willing to look at and help? If you want to write to me directly, I am very happy to look into the circumstances of that. As you know, there are a number of funding streams that the Scottish Government has to support dentistry, whether it is grants to set up new practices or to employ additional people, but that is down to a health board level. I would be very happy if you want to write to me to look into that. Thank you. My second question. I visited Postal Pharmacy and they are investing in technology to benefit patients. They have automated dispensing machines to allow out-of-hours collections. They have invested in a robot to help to create blister packs because lots of patients are unable to get help when it comes to blister packs now. Obviously, it is very expensive for them to do this, but it significantly helps the local community. Would the Scottish Government be able to make money available to help pharmacies that want to invest in these technologies for their communities? Could you create an environment where single pharmacies could group together to do something like that? I visited a pharmacy in Elin and saw similar pieces of improved technology that you saw in the one that you visited. What I was really struck with is the importance of community pharmacies within the community. I do not think that there was a minute where there was not somebody in the pharmacy. That discussion broadened out to various areas that you have touched upon in your question. I am speaking to officials about ways in which we can support and work with community pharmacies. It goes without saying that the work that they did throughout the pandemic really helped local communities and that work is continuing. It gives an opportunity for people in the communities to have a much closer interaction and sometimes a more relaxed interaction with healthcare. I think that that is incredibly important. Just coming back to the national centre for remote and rural healthcare, it is going to be commencing next month those announcements. Obviously, in my South Scotland region, it is pretty rural and remote, although we taste trinroir, for instance. Where are we with that as far as ready for an announcement next month? It was announced last week. The centre is going to be taken forward by Nez. In the first two years of the programme, we will focus on primary care. Given the specific challenges that we have in rural areas around the delivery of primary care and sustainability of primary care that has been raised this morning by Tess White, that is going to be its initial priority. It will start that work as of October next month. Just a final quick with midwifery is obviously an issue that you will be aware of in Dumfries and Galloway. Will remote and rural healthcare include midwifery approaches as well? It is not going to be. It is going to take quite a holistic approach to how it looks at some of the challenges around the delivery of healthcare in remote and rural areas and to help to inform the approach that we should take to try and address some of those challenges. That would include areas such as midwifery as part of its programme. Particularly in your constituency area, I can see that there is an area that the centre will be able to work with the local board and the different clinical groupings to try to help to look at addressing some of the challenges that they face. Okay, thank you. Thank you, convener. As a cabinet secretary, I just wanted to declare my interest as a practicing NHS GP. And final question from Tess White. Thank you, convener. Cabinet Secretary, cancer waiting times are at their worst level. We've got 800,000 people waiting for treatment. Cams and A&E waiting times are way off your own target. Got the one-year wait for outpatients are ongoing. Agency staff costs have quadrupled due to the high NHS turnover. There's a new variant of COVID. You brought forward the flu vaccination programme, so my question is, can we expect the worst winter for the NHS this year? So you'll be aware that we're taking forward, as I mentioned earlier on, a programme of work in order to tackle the backlog and waiting lists, and we can see across a range of different specialities very significant positive progress that has been made. And we're working with Boles to help to support and sustain that. We are experiencing within our healthcare system chances around recruitment of staff in the same way that the health system across the whole of the UK is experiencing real difficulties, particularly on some specialities. Some of the specialities aren't actually just difficulties for the UK. They're global challenges because of just a lack of specialists in those areas. But we are taking forward, so for example, in terms of recruitment, our specialist recruitment programme this year, we're at 93 per cent in terms of fill rate. We are at a higher fill rate at this point in the cycle than we've ever been previously, so we've got another fill rate to go to November to be finalised. So we're making very good progress in being an attractive location for clinicians to come and train and support. Our NHS, though, this winter, will experience very significant challenges. So what are we doing to try to address that? So we are expanding things like hospital at home, seeing treat programmes with the ambulance service. We are working closely with our boards around preparations they're putting in place for their A&E departments, who often feel the brunt of these challenges. And we have started our winter planning programme earlier than ever before. So one of the first pieces of work I commissioned when I came in was our winter programme, given the very challenging winter we've gone through. We've taken that forward on a joint basis with COSLA. We had a winter summit just a few weeks ago that brought all of the key stakeholders from across the country from health and social care together, the decision makers as well, to look at trying to plan and manage some of these challenges which we'll face in the course of the winter. But, yeah, it will be a challenging time. I'm not going to shy away from that, and I'm not going to kid on that it won't be difficult and that things will be perfect, but we have brought forward our planning and done it on a joint basis in a way that we have never done before, to try to help to mitigate some of the challenges which we face. In terms of our Covid vaccination and our flu vaccination programme, you'll be aware that we were going earlier, so some of that was already an earlier stage anyway than other parts of the UK. What we have done is that we've brought forward some of the Covid programme for those who are most vulnerable, just as a result of the new variant that is moving forward. But we were always one of the first parts of the UK moving forward with our winter vaccination programme. I got my flu vaccine just yesterday, so anyone who hears and heads to the flu vaccine or the Covid vaccine please take up the offer that is made. We're doing what we can to plan for the winter, for the challenges which will inevitably lie ahead, and we're also trying to put in place programmes of work that deal with the large number of people who continue to wait extended periods for treatment to try to address these issues, while at the same time also deal with the recruitment challenges that we are experiencing not just here in Scotland but across the whole of the UK, particularly in certain specialities, but so far we have made good progress, but we still have to do a lot more. Next week's meeting we will begin our pre-budgets christening for 2020-2025, and that concludes the public part of our meeting today.